11.1 Introduction

This chapter will focus on the emergence and evolvement of nurse‐led clinics in cancer services. The background to the introduction of nurse‐led clinics within healthcare will be outlined, followed by the pragmatic matters to be considered when introducing a nurse‐led clinic in any service area. There will be a focus on the advanced nursing skills required to successfully implement nurse‐led clinics and the range of approaches used. Various benefits of nurse‐led clinics for patients, the healthcare professional and the healthcare organisation will be outlined, in addition to potential barriers and suggestions to address them. The importance of service evaluation and the future of nurse‐led clinics will also be explored. The chapter will conclude with recommendations on how nurse‐led clinics can be embedded into routine practice.

The first author, Shelley Mooney, works as a band 7 uro‐oncology clinical nurse specialist (CNS) in the Northern Ireland (NI) Cancer Centre, Belfast, providing direct patient care to individuals with a diagnosis of prostate or bladder cancer, which includes being responsible for nurse‐led clinics. This author commenced this post in 2017, having previously worked in an inpatient oncology ward for five years as a band 5 registered nurse. The second author, Helen Kerr, is a senior lecturer at the School of Nursing and Midwifery, Queen’s University Belfast, with a clinical background in cancer and palliative care nursing.

11.2 Nurse‐Led Care and the Launch of Nurse‐Led Clinics in Healthcare

The evolvement of the broad term nurse‐led care has been in response to the high demand for long‐term holistic support and ongoing follow‐up (Vinall‐Collier et al. 2016). Two decades ago, Corner (2003) suggested that nurse‐led care involved nurses being delegated to accomplish specific tasks previously undertaken by medical staff. This view may be considered contentious, as Hamric and Tracy (2019) state that advanced nursing roles and responsibilities are not a substitution for medical practice. Lai et al. (2017) suggest there is no clear and consistent definition of the broad terminology of nurse‐led care but suggest that nurse‐led care involves clinics led by registered nurses who are able to work autonomously delivering person‐centred care within their area of practice and make evidence‐based clinical decisions independently. Nurse‐led care is often provided by an advanced nurse practitioner (NP) in their speciality and uses a holistic approach to patient care that takes account of the individual’s physical, psychological, social and spiritual needs (Ndosi et al. 2014).

One component of nurse‐led care is the establishment and maintenance of nurse‐led clinics. Due to the diversity of nurse‐led clinics, they are difficult to define; however, Wong and Chung (2006) state that a nurse‐led clinic is a formalised and structured healthcare delivery mode that encompasses a nurse and a client, in which a client as an individual alongside their family has healthcare needs that can be addressed by a nurse. Nurse‐led clinics first emerged in the United States of America (USA) in the 1990s and the United Kingdom (UK) in the early 2000s (McLachlan et al. 2019) in a range of chronic conditions such as cardiology and diabetes. According to Wiles et al. (2001), nurse‐led clinics were introduced in the UK to provide intermediate care to patients discharged from hospital but still needing support to regain their maximum health. Nurse‐led clinics can also support intermediate care after the acute phase of a disease (Wong and Chung 2006). As a result of their introduction, nurse‐led clinics freed up inpatient hospital beds for those requiring acute medical attention and enabled patients to receive ongoing care in an outpatient or community setting.

Nurse‐led clinics are now a crucial component of healthcare provision, as they offer an alternative to traditional physician‐led models of care and provide safe, high‐quality care (Connolly and Cotter 2021). Nurse‐led clinics are often the responsibility of an advanced practice nurse, such as an NP or a CNS. The development of advanced practice nurses was an important milestone in the professional development of the nursing discipline throughout the twentieth century and has become a global trend in the twenty‐first century. Nurse‐led clinics serviced by advanced practice nurses have become common international practice since the 1990s (Shiu et al. 2011). According to Randall et al. (2017), nurse‐led clinics are now established worldwide in various clinical settings and are reported as an effective method of patient assessment and care.

11.3 Components of a Nurse‐Led Clinic

Hatchett (2016) outlines that nurse‐led clinics involve nurses having their own patient workload, which requires increased autonomy and often using advanced clinical skills such as physical assessment, diagnosis and medication management. For a registered nurse to lead their own clinic, they must demonstrate advanced competence to practice in a specific healthcare area and practice either independently and/or interdependently with other members of a healthcare team in at least 80% of their work (Wong and Chung 2006). Nurse‐led clinics are reported to be commonly focused on treating and managing chronic conditions (Randall et al. 2017). According to the International Council of Nursing (ICN) (2021), key to nurse‐led clinics is the central role of the CNS, who has an understanding of the patient and their condition and can develop a trusting relationship with the patient. To effectively lead a clinic, the majority of the caseload should be protocolised, which empowers the nurse to lead the clinic without the need for support from other healthcare professionals; however, there will be situations where unique patient cases present, requiring support from other healthcare professionals and leading to opportunities for further learning and development.

In the context of cancer care, the National Cancer Plan in the UK (Department of Health 2000) stated that cancer services needed to be re‐designed to make the best use of skills within the cancer workforce and ensure that patients and their families had appropriate and timely access to supportive aftercare. Thus, support and follow‐up after treatment were important in the development of cancer services, and as a result, numerous nurse‐led activities emerged, such as nurse‐led clinics (Cox and Wilson 2003). Furthermore, an ambitious strategy launched by the Independent Cancer Taskforce (2015) aimed to transform cancer care between 2015 and 2020 through alternative models of patient care after cancer treatment, such as follow‐up carried out by a specialist nurse. Nurse‐led follow‐up was identified as a suitable means of follow‐up in cancer care, and its acceptability has been widely demonstrated in lung, breast, prostate and bladder cancer (Smits et al. 2015) and continues to be developed in other tumour sites. Nurse‐led clinics are now embedded into routine clinical practice in cancer care for a range of tumour sites.

Nurse‐led clinics differ in purpose and functionality. Whilst some nurse‐led clinics are focused on patient assessment and management, others focus on the CNS being in a more supportive role. Nurse‐led clinics may include health assessments to manage a patient’s health condition and symptoms, health education to facilitate compliance and a healthy lifestyle, and co‐ordination of care using a holistic approach (Wong and Chung 2006). Within cancer care, a diverse range of nurse‐led clinics may be available throughout the patient pathway, and often the disease site dictates what type of nurse‐led clinic is suitable for which patient group. Depending on the tumour site, a nurse‐led clinic may be available when the individual receives a diagnosis; for other tumour sites, the nurse‐led clinic may be available at treatment review, during radiotherapy or systemic anti‐cancer therapy (SACT), post‐treatment follow‐up, or for a holistic needs assessment (HNA) to be completed. According to Campbell et al. (2000), whilst the primary aim of a nurse‐led radiotherapy review clinic was to monitor radiation reactions and tolerance to treatment and manage radiotherapy‐related toxicities, it also provided the nurse with an opportunity to assess the patient for physical, psychological and social problems, contributing to a holistic approach to care.

The Macmillan Cancer Support Recovery Package and National Health Service (NHS) England highlight the potential benefits of risk‐stratifying follow‐up of individuals with cancer (Macmillan Cancer Support 2015; NHS England 2016). In terms of post‐treatment follow‐up, certain disease sites, such as prostate and breast cancer, have large cohorts of patients who require long‐term follow‐up over many years (National Institute of Clinical Excellence 2021). In response to UK national guidelines, many nurses now provide this routine follow‐up to bridge gaps where medical follow‐up may be ceasing due to high clinical demands for increasing new patient diagnoses and the development of new treatment modalities (Sheppard 2007).

11.4 Introducing a Nurse‐Led Clinic

Introducing a nurse‐led clinic requires meticulous planning and takes time to ‘pull together’ (Jones et al. 2016). Hatchett (2008) identifies a 10‐step process when establishing a new service. In summary, these 10 key steps include building a business case, defining aims and objectives, establishing patient criteria, planning publicity, determining the clinic location, gaining support from colleagues, planning professional development, considering medicine management if appropriate, planning audit and evaluation and, finally, facilitating ongoing improvement. Following these 10 steps enhances a nurse’s ability to introduce and effectively establish a nurse‐led clinic.

Prior to embarking on any new developments within healthcare, Judd (2009) outlines the importance of establishing whether there is a service need, which involves pre‐determining which patient groups are appropriate. This can be facilitated with discussions with relevant clinical team members to identify current gaps in practice to determine whether a nurse‐led clinic would be a suitable solution to address the service need. In terms of appropriate patient groups, patients with straightforward protocolised follow‐up are often deemed suitable to attend a nurse‐led clinic. These clinics have strict inclusion and exclusion criteria; therefore, only patients who meet these criteria should be referred.

Furthermore, clear communication with all multidisciplinary team members is crucial in the initial planning stage, and those influenced by the service change should be included in these discussions in addition to the planning processes. This should include management, relevant healthcare professionals and administrative teams. Setting up a nurse‐led clinic in any speciality may pose challenges due to a potential change in practice. Hatchett (2005) states that ensuring all staff influenced by the change are kept informed and that their opinions are valued, should lead to a smoother transition to change when introducing a new clinic. A team approach is also required, which includes all stakeholders, such as administrative staff and both medical and nursing healthcare professionals. A team approach will facilitate administrative staff and healthcare professionals to provide their valuable input, contributing to the smooth introduction of a nurse‐led clinic (Hatchett 2005).

A hierarchy of support is crucial, including the logistics and costs associated with introducing a nurse‐led clinic. Indirect costs may include room allocation, information technology support and clinical supervision for nursing staff provided by medical staff such as oncologists. In addition to these indirect costs, direct costs include CNS staffing for the nurse‐led clinic. A nurse‐led clinic is often embedded into the CNS’s current job plan; therefore, finances to support this component of the role are allocated from this budget with no additional cost (Moore 2018).

When logistics such as room allocation have been considered and a hierarchy of support is secured, Judd (2009) suggests the need for a robust protocol to support advanced nursing practice independently. Initial standard operating procedures and protocols must be developed alongside an assessment record. An assessment record acts as a template to guide the nurse when assessing patients to ensure that all required information is included to reduce the risk of omitting vital data. These documents should be developed within the team with refinements provided by oncologists and agreement with written information approval groups (or equivalent) and document control (Jones et al. 2016).

Robust protocols are essential to deliver independent nurse‐led clinics. Protocols must cover expected patient presentations and potential non‐expected presentations associated with the condition that may arise, alongside an action plan. The importance of these protocols is to assist and direct nurses in their clinical decision‐making. Protocols must be agreed upon by the referring clinicians and validated by the hospital’s Clinical Governance Committee (or equivalent). However, Judd (2009) advises that nurses must be cautious not to ‘fit the patient to the protocol’, so the nurse in charge of the clinic must draw on their knowledge and expertise when presented with new situations and acknowledge and work within their limitations. Furthermore, Gousy and Green (2015) highlight that a person‐centred approach is a vital component of nurse‐led clinics to ensure that the clinic is designed to meet the needs of the person and not limited to the clinical diagnosis.

Nursing documentation is essential in the nurse‐led clinic, as it provides evidence regarding the patient’s progress and/or any complications that require further interventions (Leahy et al. 2013). Individualised assessment records specific to each cancer site may be developed and used for nurse‐led clinics to record symptoms reviewed, blood test results and any follow‐up plans (Robertson et al. 2013). In 2016, a Regional Information System for Oncology and Haematology (RISOH) (Northern Ireland Cancer Network 2022) was introduced in NI: it is an online system for documenting patient information. Within RISOH, healthcare professionals can type freehand or complete a template questionnaire about their contact with patients. The online information is available for all healthcare professionals within oncology and haematology. This up‐to‐date, real‐time, accurate documentation enhances patient safety and promotes clear communication between teams. In addition, template questionnaires are an excellent resource for recently appointed CNSs responsible for nurse‐led follow‐up clinics, as they ensure that all relevant patient information is available.

11.5 Nursing Skills Required to Introduce and Establish a Nurse‐Led Clinic

All registered nurses must demonstrate competencies in a range of skills, such as communication and clinical skills. Nurses who work in advanced practice roles must also demonstrate expertise in the four pillars of advanced practice (Lee et al. 2020): clinical, research, education and management/leadership. Furthermore, Wong and Chung (2006) highlight that CNSs must possess credibility in a relevant speciality area; be capable of contributing to enhancing the quality of service; be competent in project management, research, leadership and people skills; and possess the personal qualities of creativity, flexibility, confidence, assertiveness and perceptiveness.

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